PENETRATING GUNSHOT WOUND OF THE ABDOMEN.?LAPAROTOMY. By Surgeon-Major J.
O'BRIEN,
f.r.c.s.e.
Civil Surgeon, Darjeeling.
On the 4th June last, at 11 a.m., Mrs. X, a healthy Native lady, aged 24, and the mother of three or four children, was accidentally shot by her brother, a lad of 10,with a pocket revolver. The boy was playing with the revolver, believing it, as his sister did, to be unloaded, when suddenly there was a loud explosion, and the lady was struck by the bullet in the abdomen from a distance of two yards. It appears that a stray bullet had either been left in the chambers of the weapon or had been placed there by one of the other children who sometimes used it as a toy. She fell to the ground at once, but] the There was but little shock was not severe. external haemorrhage, only a few drops of blood trickling from the wound, and the only pain experienced was a sense of burning at the point of entrance of the bullet. I arrived at 12-30 p.m. and found the lady lying in bed; face rather anxious, pulse slow, extremities inclined to be cold, but no sign of There was a small cirsevere surgical shock. cular wound with charred appearance at the edges on the abdomen, four inches to the right of, and on the same level as the umbilicus. It lay just external to a line drawn vertically upwards from the anterior superior spine of the ileum to A long probe the cartilage of the 10th rib. was carefully passed into the wound. It entered readily for some six or eight inches towards the opposite side of the pelvis in a direction iuwards, backwards and downwards, thus showing that the abdominal cavity had been penetrated. No trace of the bullet could be discovered with the probe. I examined a similar bullet from another cartridge, and fouud that it was. conical in shape, a little more than a half inch
slightly
INDIAN MEDICAL GAZETTE.
10,
long, one-fourth inch in diameter, and that its weight was one-and-a-half drachm. 'Seeing that the bullet had passed through the
I considered it advisable, even in the absence of severe symptoms, to open the abdominal cavity to ascertain what internal injuries It was highly probable had been received. (1) that some small vessel in the omentum, mesentery or intestine, had been wounded and would need ligature ; (2) that blood had been extravasated close to the parietal wound and would have, owing to danger of decomposition and consequent peritonitis, to be removed; (3) that the intestine, bladder or other viscus had been wounded, and would have to be dealt with ; (4) that the bullet could be discovered and removed, and last but not least it, struck me as desirable to shut off the contused and charred parietal wound, which was bound to slough later on, from the cavity of the abdomen by careful suturing of the peritoneum at the seat of injury and by drainage externally. To have waited until symptoms of peritonitis or of severe hcemorrhage supervened would have been, I thought, decidedly adverse to the patient's chances of recovery.
abdomen,
Chloroform was accordingly administered by Mr. Milchem, the Resident Medical Officer of the Eden Sanitarium, who assisted me. Then,
antiseptic precautions, I made a verlength and having mid its as w;ound point. On dividing the
with strict
tical incision three inches in
the skin and thick layer of fat, the aperture in the The various muscles came plainly into view. layers of the muscles were next cautiously Here a divided and the peritoneum exposed. small opening indicating the track of the bullet was also plainly seen. Bleeding, which was very slight, haviug been controlled, the peritoneum was slit on a director for about 2?". Beneath it the omentum came into view, lying upon the coils of the small intestine, and in it (omentum) a small circular hole corresponding to the peritoneal wound was perceived, but this was the last that could be discovered of the track of the bullet. I carefully raised the omentum and inspected the coils of the small intestine, but could not detect the slightest sign of any injury. I then inserted first one finger and afterwards nearly the whole hand in the vain search for the missile, which appeared to have passed without doing harm between the coils of the gut towards the opposite side of the pelvis, where it probably got imbedded iu the substance of the psoas or iliacus muscles. A thorough exploration of the abdomen and of the pelvis near the course of the bullet was made, but no further trace of it could ba found. The bladder, the uterus aud its appendages, the rectum, the kidneys and the bodies of the lower vertebra} were successively The aorta close to its bifurcation aud the felt. large veins came under the hand, but there was no vestige of the bullet; neither was there any
[Jan.
1892.
extravasated blood, nor was there sign or smell of escape of fasces from the bowel. As further search for the bullet appeared to be useless, and as 110 wound of the viscera had been detected, I immediately proceeded to close For this purpose I employed three the incision. sets of sutures, viz., one for the peritoneum, one for the muscles, and the third for the skin and fat. As it was of the utmost importance that the abdominal cavity should be securely closed, I brought the edges of the peritoneum into close apposition, and slightly everting secured them The bullet hole with eight sutures of fine silk. which was small did not present any obstacle to the accurate approximation of this membrane. The muscles were then evenly drawn together with gut, and the skin loosely with horse-hair. Between skin and muscles a drainage tube was placed. The wound was dressed with Lister's protective and sal alembroth wool, and the patient placed comfortably in bed with the knees bent over a pillow. The operation lasted for about an hour. As it appeared to be possible that the intestine had been penetrated by the small bullet at some point whichhad escaped my notice, I thought it safest to administer morphia in small doses to check peristaltic action and to put the patient on low diet for a few days. 25 minims of Liq. were accordingly given in Hydrochlor. Morphia) a couple of drachms of water shortly after she recovered from the chloroform. The further
7-15
course
of the
case was as
follows
:
m.?Temperature 100*5?; pulse small and quick, patient restless, much nausea and vomiting. .No urine passed since morning, catheter had to be introduced : 10 oz. highly colored urine drawn off. Repeat morphia draught at bedtime, only a few spoonfuls of milk aud water
given
p.
as
5th
food.
June,
6
A.
M.?Temp. 99'8?; slept badly;
continues. 9-30
a. m., temperature 100*5?. Uriue drawn off with catheter; some pain aud tenderness in the abdomen. The dressings which were soaked by sanious discharge from the external wound were changed. Wound looks healthy ; 110 sign of inflammation; diet milk and barley water in spoonfuls.
nausea
6
p. M.
?
Temp.
99*8?. Catheter
passed.
Nau-
ordered; drinks to be iced and pieces given to the patient to suck. 6th.?Morning temp. 98*4?. Sickness relieved ; patient feels better, tenderness in abdomen continues, but there is little pain. Dressings changed. sea
continues ; ice
There is free
suppuration
from the
external
wound; dressings soaked, diet improved;?chicken broth, a wineglassful every 3 hours; also milk aud
barley water. Still unable to pass water, probably owing to the soreness of the wound and the difficulty of using the abdominal muscles.
Evening temp.
99,2?.
Jan.
GUNSHOT WOUND OF THE ABDOMEN.
1892.]
1th.?Morning temp. 98*6. Slept well; dressings changed; pus in large quantity discharged from
the
wound.
Flatus
freely passed
this
morning. Catheter still required. Some pain in epigastrium complained of. Morphia to be continued.
Evening temp. 100?. 8th.?Morning temp.
99'2?. Slept well; feels in the external wound. except
pain passed naturally. Dressings changed. Copious discharge of pus. Morphia pills to be
easy; Urine
no
continued.
Evening temp. 99'6?. Feels easy, urine passed naturally ; flatus freely passed during the day. $th.?Slept well; no pain. Several small sloughs came through the tube. As the wouud was discharging pus and small sloughs copiously, I broke down the adhesions of the edges of the
skin
over
the lower half of the wound so as to the removal
permit of a thorough cleansing and of sloughs. Morning temp. 98'4?. Evening temp. 99*6?. lCM/e.?Morning temp.
98"4?. Bowels not As discomfort is moved since the operation. now felt on this account a soap and water enema This produced a copiwas given this morning. I had the stool ous evacuation of scybalce, &c. washed to make sure that the bullet had not passed by the bowel but no sign of it discovered. Dressings changed, a few of the gut sutures of the muscles came away with some small
sloughs to-day. Evening temp. 99'2?. ?Morning temp. 98'8?. Copious purulent discharge in the dressings as before. Evening temp. 99*4?. 12th.?Temp, normal. Patient doing well. 15th.?External wouud clean aud free from sloughs. Temperature normal.
18^/i.?A few of the fine silk sutures employed for the peritoneum came away this morning with a shred of slough of this membrane included. From this date the patient did well. I discontinued my daily visits on the 22ud. The external wound, however, took a long time to heal. It was two mouths or more from the date of the injury before it had healed permanently. The patient is now. i? her usual state of health, active and busy, aud though the bullet is still buried iu some part of the abdomen or pelvis it causes so little inconvenience that she has not the slightest intimation of its precise situation. Remarks.?It may be said or thought that it was unnecessary to open the abdomen in this case. In reply to any such objection, I give the following quotation from the latest edition (1891) of the Surgeon's Pocket Book. " The prognosis of wounds of the abdomen is very unfavourable, the diagnosis very obscure, and the results of treatment discouraging. It is therefore most important that the question as to penetration of the abdominal cavity should
lj
be settled as speedily as possible, and this can be most easily determined by passing a probe into the wound. MacCormac adds: " And if this fails to clearly establish the fact or otherwise of penetration the wound should be enlarged and explored to its termination either iu the paiietes or more deeply." (Abdominal Section by Sir W. MacCormac, 1887.) "Abdominal section for penetrating wounds is steadily gaining adherents, it being admitted that the mortality has been materially decreased since its introduction, and that the intrinsic risk of an abdominal section for exploratory purr poses is, if properly performed, very slight. It must always be remembered that to wait for symptoms of perforation of intestine to apparr in a case of penetrating abdominal wound is greatly to decrease the chauce of recovery, and some surgeons advocate immediate exploration in all such cases." (Year Book, 1890.) 1 have to thank Dr. Dutt, of Beadon Street, Calcutta, who joined me in the treatment of the patient, on the afternoon of 5th June, for the notes from which I have written out this case.
O'BRIEN,
f.r.c.s.e.
Civil Surgeon, Darjeeling.
On the 4th June last, at 11 a.m., Mrs. X, a healthy Native lady, aged 24, and the mother of three or four children, was accidentally shot by her brother, a lad of 10,with a pocket revolver. The boy was playing with the revolver, believing it, as his sister did, to be unloaded, when suddenly there was a loud explosion, and the lady was struck by the bullet in the abdomen from a distance of two yards. It appears that a stray bullet had either been left in the chambers of the weapon or had been placed there by one of the other children who sometimes used it as a toy. She fell to the ground at once, but] the There was but little shock was not severe. external haemorrhage, only a few drops of blood trickling from the wound, and the only pain experienced was a sense of burning at the point of entrance of the bullet. I arrived at 12-30 p.m. and found the lady lying in bed; face rather anxious, pulse slow, extremities inclined to be cold, but no sign of There was a small cirsevere surgical shock. cular wound with charred appearance at the edges on the abdomen, four inches to the right of, and on the same level as the umbilicus. It lay just external to a line drawn vertically upwards from the anterior superior spine of the ileum to A long probe the cartilage of the 10th rib. was carefully passed into the wound. It entered readily for some six or eight inches towards the opposite side of the pelvis in a direction iuwards, backwards and downwards, thus showing that the abdominal cavity had been penetrated. No trace of the bullet could be discovered with the probe. I examined a similar bullet from another cartridge, and fouud that it was. conical in shape, a little more than a half inch
slightly
INDIAN MEDICAL GAZETTE.
10,
long, one-fourth inch in diameter, and that its weight was one-and-a-half drachm. 'Seeing that the bullet had passed through the
I considered it advisable, even in the absence of severe symptoms, to open the abdominal cavity to ascertain what internal injuries It was highly probable had been received. (1) that some small vessel in the omentum, mesentery or intestine, had been wounded and would need ligature ; (2) that blood had been extravasated close to the parietal wound and would have, owing to danger of decomposition and consequent peritonitis, to be removed; (3) that the intestine, bladder or other viscus had been wounded, and would have to be dealt with ; (4) that the bullet could be discovered and removed, and last but not least it, struck me as desirable to shut off the contused and charred parietal wound, which was bound to slough later on, from the cavity of the abdomen by careful suturing of the peritoneum at the seat of injury and by drainage externally. To have waited until symptoms of peritonitis or of severe hcemorrhage supervened would have been, I thought, decidedly adverse to the patient's chances of recovery.
abdomen,
Chloroform was accordingly administered by Mr. Milchem, the Resident Medical Officer of the Eden Sanitarium, who assisted me. Then,
antiseptic precautions, I made a verlength and having mid its as w;ound point. On dividing the
with strict
tical incision three inches in
the skin and thick layer of fat, the aperture in the The various muscles came plainly into view. layers of the muscles were next cautiously Here a divided and the peritoneum exposed. small opening indicating the track of the bullet was also plainly seen. Bleeding, which was very slight, haviug been controlled, the peritoneum was slit on a director for about 2?". Beneath it the omentum came into view, lying upon the coils of the small intestine, and in it (omentum) a small circular hole corresponding to the peritoneal wound was perceived, but this was the last that could be discovered of the track of the bullet. I carefully raised the omentum and inspected the coils of the small intestine, but could not detect the slightest sign of any injury. I then inserted first one finger and afterwards nearly the whole hand in the vain search for the missile, which appeared to have passed without doing harm between the coils of the gut towards the opposite side of the pelvis, where it probably got imbedded iu the substance of the psoas or iliacus muscles. A thorough exploration of the abdomen and of the pelvis near the course of the bullet was made, but no further trace of it could ba found. The bladder, the uterus aud its appendages, the rectum, the kidneys and the bodies of the lower vertebra} were successively The aorta close to its bifurcation aud the felt. large veins came under the hand, but there was no vestige of the bullet; neither was there any
[Jan.
1892.
extravasated blood, nor was there sign or smell of escape of fasces from the bowel. As further search for the bullet appeared to be useless, and as 110 wound of the viscera had been detected, I immediately proceeded to close For this purpose I employed three the incision. sets of sutures, viz., one for the peritoneum, one for the muscles, and the third for the skin and fat. As it was of the utmost importance that the abdominal cavity should be securely closed, I brought the edges of the peritoneum into close apposition, and slightly everting secured them The bullet hole with eight sutures of fine silk. which was small did not present any obstacle to the accurate approximation of this membrane. The muscles were then evenly drawn together with gut, and the skin loosely with horse-hair. Between skin and muscles a drainage tube was placed. The wound was dressed with Lister's protective and sal alembroth wool, and the patient placed comfortably in bed with the knees bent over a pillow. The operation lasted for about an hour. As it appeared to be possible that the intestine had been penetrated by the small bullet at some point whichhad escaped my notice, I thought it safest to administer morphia in small doses to check peristaltic action and to put the patient on low diet for a few days. 25 minims of Liq. were accordingly given in Hydrochlor. Morphia) a couple of drachms of water shortly after she recovered from the chloroform. The further
7-15
course
of the
case was as
follows
:
m.?Temperature 100*5?; pulse small and quick, patient restless, much nausea and vomiting. .No urine passed since morning, catheter had to be introduced : 10 oz. highly colored urine drawn off. Repeat morphia draught at bedtime, only a few spoonfuls of milk aud water
given
p.
as
5th
food.
June,
6
A.
M.?Temp. 99'8?; slept badly;
continues. 9-30
a. m., temperature 100*5?. Uriue drawn off with catheter; some pain aud tenderness in the abdomen. The dressings which were soaked by sanious discharge from the external wound were changed. Wound looks healthy ; 110 sign of inflammation; diet milk and barley water in spoonfuls.
nausea
6
p. M.
?
Temp.
99*8?. Catheter
passed.
Nau-
ordered; drinks to be iced and pieces given to the patient to suck. 6th.?Morning temp. 98*4?. Sickness relieved ; patient feels better, tenderness in abdomen continues, but there is little pain. Dressings changed. sea
continues ; ice
There is free
suppuration
from the
external
wound; dressings soaked, diet improved;?chicken broth, a wineglassful every 3 hours; also milk aud
barley water. Still unable to pass water, probably owing to the soreness of the wound and the difficulty of using the abdominal muscles.
Evening temp.
99,2?.
Jan.
GUNSHOT WOUND OF THE ABDOMEN.
1892.]
1th.?Morning temp. 98*6. Slept well; dressings changed; pus in large quantity discharged from
the
wound.
Flatus
freely passed
this
morning. Catheter still required. Some pain in epigastrium complained of. Morphia to be continued.
Evening temp. 100?. 8th.?Morning temp.
99'2?. Slept well; feels in the external wound. except
pain passed naturally. Dressings changed. Copious discharge of pus. Morphia pills to be
easy; Urine
no
continued.
Evening temp. 99'6?. Feels easy, urine passed naturally ; flatus freely passed during the day. $th.?Slept well; no pain. Several small sloughs came through the tube. As the wouud was discharging pus and small sloughs copiously, I broke down the adhesions of the edges of the
skin
over
the lower half of the wound so as to the removal
permit of a thorough cleansing and of sloughs. Morning temp. 98'4?. Evening temp. 99*6?. lCM/e.?Morning temp.
98"4?. Bowels not As discomfort is moved since the operation. now felt on this account a soap and water enema This produced a copiwas given this morning. I had the stool ous evacuation of scybalce, &c. washed to make sure that the bullet had not passed by the bowel but no sign of it discovered. Dressings changed, a few of the gut sutures of the muscles came away with some small
sloughs to-day. Evening temp. 99'2?. ?Morning temp. 98'8?. Copious purulent discharge in the dressings as before. Evening temp. 99*4?. 12th.?Temp, normal. Patient doing well. 15th.?External wouud clean aud free from sloughs. Temperature normal.
18^/i.?A few of the fine silk sutures employed for the peritoneum came away this morning with a shred of slough of this membrane included. From this date the patient did well. I discontinued my daily visits on the 22ud. The external wound, however, took a long time to heal. It was two mouths or more from the date of the injury before it had healed permanently. The patient is now. i? her usual state of health, active and busy, aud though the bullet is still buried iu some part of the abdomen or pelvis it causes so little inconvenience that she has not the slightest intimation of its precise situation. Remarks.?It may be said or thought that it was unnecessary to open the abdomen in this case. In reply to any such objection, I give the following quotation from the latest edition (1891) of the Surgeon's Pocket Book. " The prognosis of wounds of the abdomen is very unfavourable, the diagnosis very obscure, and the results of treatment discouraging. It is therefore most important that the question as to penetration of the abdominal cavity should
lj
be settled as speedily as possible, and this can be most easily determined by passing a probe into the wound. MacCormac adds: " And if this fails to clearly establish the fact or otherwise of penetration the wound should be enlarged and explored to its termination either iu the paiietes or more deeply." (Abdominal Section by Sir W. MacCormac, 1887.) "Abdominal section for penetrating wounds is steadily gaining adherents, it being admitted that the mortality has been materially decreased since its introduction, and that the intrinsic risk of an abdominal section for exploratory purr poses is, if properly performed, very slight. It must always be remembered that to wait for symptoms of perforation of intestine to apparr in a case of penetrating abdominal wound is greatly to decrease the chauce of recovery, and some surgeons advocate immediate exploration in all such cases." (Year Book, 1890.) 1 have to thank Dr. Dutt, of Beadon Street, Calcutta, who joined me in the treatment of the patient, on the afternoon of 5th June, for the notes from which I have written out this case.
